Elbow Conditions
Pronator Teres syndrome
Supinator syndrome
Ulnar sulcus syndrome
SEE LEAF and WALTHER MANUALS
FOR IN DEPTH DISCUSSION
©Zatkin/Stark 2007
Pronator Teres Syndrome
Entrapment of Median nerve between ulnar and
radial heads of Pronator Teres muscle
– most common site of compression caused by muscle
hypertrophy or thickening of aponeurotic fascia
between two heads of pronator teres
Median nerve enters forearm passing between
the two heads of pronator teres and then deep
to flexor digitorum superficialis arch, continuing
between flexor digitorum superficialis and flexor
digitorum profundus in forearm
©Zatkin/Stark 2007
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Pronator Teres Syndrome…
There are four reported sites of median nerve
compression
1. pronator teres: most common
2. flexor digitorum superficialis arch: second most
common, fibrosis of flexor digitorum superficialis
arch
3. supracondylar process/ligament of struthers
4. lacertus fibrosis (bicipital aponeurosis)
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Lacertus Fibrosis
The lacertus fibrosis, an aponeurotic
expansion, originates at the
musculotendinous junction of biceps
brachii medially and blends distally with
fascia of superficial flexor mass and
inserts on proximal ulna
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Pronator Teres Syndrome…
Symptoms of decreased hand strength,
problems with writing, numbness/tingling in hand
and especially palm, pain in proximal forearm,
fatigue with exercise
– Signs and symptoms usually worse with activity
– Nocturnal symptoms seen with carpal tunnel
syndrome are typically absent
– Negative Phalen's test
– Weakness of median innervated muscles may only
appear after provocative tests (resisted pronation)
©Zatkin/Stark 2007
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Pronator Teres Syndrome…
Weakness of finger flexors (ie: flexor digitorum
profundus)
– Strengthens with approximation of proximal radius
and ulna
©Zatkin/Stark 2007
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Pronator Teres Syndrome…
1. Challenge radial head and adjust
– Often superior or lateral
2. Test Pronator teres for proper function
– Weakness
– Shortened : SCS/RSCS, FF, etc
– Test for core muscle dysfunction
Esp transverse abdominis
©Zatkin/Stark 2007
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Median Nerve Provocative tests
– Resisted forearm pronation for 30 to 60 seconds
demonstrates compression at pronator teres when
symptoms are reproduced
– Resisted elbow flexion and supination of the forearm
can localize compression to lacertus fibrosis
– Resisted long-finger flexion localizes lesion at level of
flexor digitorum superficialis (FDS) arch
– Supracondylar process can be palpated on medial
humeral surface and confirmed with radiographs
– EMG/NCV is inconsistent and diagnosis should be
made clinically
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Lacertus Fibrosis
The lacertus fibrosis can be deformed by
trauma, repetitive stress, or imbalance of
triceps and biceps brachii
Biceps brachii is elbow flexor and most
powerful forearm supinator
– can be inhibited by over-facilitated triceps due
to pancreatic hyperfunction
– Hyperinsulinism very common!
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Supinator Syndrome
Entrapment of Radial nerve beneath Supinator
muscle
Symptoms with repetitive forearm motions
– esp. throwing
Decreased hand strength, pain deep in posterior
forearm
Weakness of extensor carpi ulnaris
– Strengthens with approximation of proximal radius
and ulna or with lower arm in full supination
©Zatkin/Stark 2007
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Supinator Syndrome…
Test Supinator for normal function
– especially fascial involvement
– Test for core muscle dysfunction
Esp transverse abdominis
©Zatkin/Stark 2007
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Ulnar Sulcus Syndrome
Entrapment of ulnar nerve in ulnar sulcus
of medial epicondyle of humerus
– due to laxity or enlargement of epicondyloolecranon ligament
Symptoms of numbness/tingling and/or
pain in ulnar nerve distribution
©Zatkin/Stark 2007
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Ulnar Sulcus Syndrome…
Weakness of flexor carpi ulnaris in elbow
flexion but usually not in extension
– Challenge humerus and ulna and adjust
– Test ligament for fascial shortening and raw
bone supplementation
©Zatkin/Stark 2007
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